Regional Lymphatic Inclusion in Orthotopic Hindlimb Transplantation: Establishment and Assessment of Feasibility in a Rodent Model.

BACKGROUND: The lymphatic system may play an important role in local immunomodulation in vascularized composite allotransplantation (VCA). Currently, there is no standardized VCA model that includes the regional draining lymphatic tissue. The aim of this study was to develop a rapid and efficient orthotopic hindlimb transplantation model in rats that included the draining lymphatic basin to permit further evaluation of the lymphatic system's role in VCA. METHODS: Thirty transplantations from Brown Norway rats to Lewis rats were performed. To include the regional lymphatic tissue, the superficial epigastric vessels were preserved to allow retrieval of the corresponding inguinal lymph nodes, including the inguinal fat pad, with the hindlimb. A cuff technique was used for the vein, whereas the conventional microsurgical technique was used for the arterial anastomosis. Vascular patency was confirmed through laser Doppler analysis at postoperative day 1 and histological analysis after euthanasia. RESULTS: The presence and vascularization of the inguinal lymph nodes were verified with indocyanine green lymphoscintigraphy at the time of transplantation. Mean total ischemia time was 69 ± 24 minutes, and mean recipient operation time was 80 ± 19 minutes. Overall transplant survival rate was 93.3%. Laser Doppler analysis showed vascular (technical) success, indocyanine green lymphoscintigraphy confirmed the presence of lymph nodes and the histological analysis revealed patent anastomoses. CONCLUSIONS: We successfully developed an experimental orthotopic hindlimb transplantation model in rats that includes the draining inguinal lymphatic basin, which is an important asset in further research on lymphatic tissue and its role in VCA.

Non-vascularized partial joint transfer for Finger Proximal Interphalangeal joint reconstruction: a series of 9 patients.

INTRODUCTION: Finger proximal interphalangeal joint (PIP) reconstruction after the destruction of parts of the joint remains challenging. Surgical techniques include implant arthroplasty, arthrodesis, free vascularized joint transfer, and non-vascularized bone and joint transfer. This study analyzes our experience after non-vascularized transfer in terms of range of motion, postoperative rehabilitation, and patient satisfaction. MATERIALS AND METHODS: Between 2009 and 2014, ten patients underwent non-vascularized partial joint transfer for PIP joint reconstruction. One of them was lost to follow-up. Included patients had osteochondral partial joint transplants of 25-50% of the toes (n = 4) and the hand (n = 5). Range of motion (ROM), grip-, and pinch-strength were measured at the last follow-up control and compared to the healthy side. Patients were asked to score the pain at rest/ on load on a visual scale (VAS: 0 = no pain; 10 = excruciating pain). Satisfaction self-assessment was evaluated by asking the patients to grade their postoperative result as excellent, very good, good or poor. RESULTS: Mean follow-up period was 4.0 years (range 1.2-7.9 years). Mean PIP joint flexion was 93 ± 26° at the last follow-up control. Mean grip- and pinch-strength of the operated side at the last control were, respectively, 43 ± 18 kg and 8 ± 5 kg, close to the healthy side values (45 ± 15 kg and 9 ± 4 kg). Mean pain at rest/on load measured on a visual scale was, respectively, 0.3 ± 1 and 1.8 ± 2. Eight patients (89%) rated their operation as excellent, and one as poor. CONCLUSION: In this study, non-vascularized partial joint transfer provides a mobile and stable PIP joint 4 years after reconstruction. The surgical technique presented herein is complex depending on additional injuries but results in great patient satisfaction.

Range of motion, postoperative rehabilitation and patient satisfaction in MCP and PIP joints affected by Dupuytren Tubiana stage 1-3: collagenase enzymatic fasciotomy or limited fasciectomy? A clinical study in 52 patients.

INTRODUCTION: In Switzerland, collagenase Clostridium histolyticum therapy (CCH) for Dupuytren's disease was introduced in 2011. This study analyzes possible differences between CCH and limited fasciectomy (LF) in terms of range of motion, patient satisfaction and postoperative rehabilitation. MATERIALS AND METHODS: This retrospective study included 52 patients with Dupuytren's disease stage 1-3 according to Tubiana, treated with CCH or LF between January 2012 and December 2013. Complications were analyzed for each patient. The contracture of each treated joint measured on average at the 3 months and up to 2 years follow-up was compared with the preoperative values. The Michigan Hand score was evaluated at 2 years and the patients were asked to subjectively evaluate the outcome of the treatment and whether they would repeat it if necessary. Postoperative rehabilitation was also precisely quantified. RESULTS: 11 minor complications were reported for a complication rate of 29% in the CCH group. No major complications were reported in both groups. In the CCH group, mean MCP joint contracture was, respectively, 44° ± 20°, 9° ± 2° (gain of mobility compared to the preoperative situation 35°, P < 0.001), and 10° ± 3° (gain 34°, P < 0.001), respectively, before, at the 3 months' control and at the 2-year clinical control. In the LF group, mean MCP joint contracture was, respectively, 30° ± 21°, 2° ± 0.5° (gain 28°, P < 0.001), and 1° ± 0.5° (gain 29°, P < 0.001) for the same control periods. In the CCH group, mean PIP joint contracture was, respectively, 51° ± 21°, 18° ± 3° (gain of mobility compared to the preoperative situation 33°, P < 0.001), and 32° ± 4° (gain 19°, P < 0.001), respectively, before, at the 3 months' control and at the 2-year clinical control. In the LF group, mean PIP joint contracture was, respectively, 30° ± 20°, 2° ± 0.5° (gain of mobility compared to the preoperative situation 28°, P < 0.001), and 11° ± 4° (gain 19°, P < 0.001) for the same control periods. Outcomes were compared across the LF and CCH groups: surgery performed better than collagenase for PIP joint treatment at early (P < 0.001) and 2-year follow-up (P = 0.004) controls. However, patient satisfaction was higher in the CCH group: 92% were satisfied or very satisfied of the treatment compared to 71% in the LF group. All patients would reiterate the treatment in the CCH group if necessary compared to only 71% in the LF group. Rehabilitation was highly reduced in the CCH group compared to the LF group. CONCLUSION: In this study, surgery performed better than collagenase at early and 2-year follow-up in PIP joints and similar in MCP joints. While surgery seems to achieve better results, collagenase is considered in Switzerland as an off-the-shelf therapy that provides consistent results without scars, with shorter rehabilitation time, minor hand therapy, shorter splinting time, and applicability. LEVEL OF EVIDENCE AND STUDY TYPE: Level III.

Intra-graft injection of tacrolimus promotes survival of vascularized composite allotransplantation.

BACKGROUND: Immunosuppressive therapies derived from solid organ transplantation are effective in promoting survival of vascularized composite allotransplantation (VCA), but they cause serious side effects that are difficult to justify for this non-life-saving procedure. Unlike solid organ transplantation, hand and face transplants offer the possibility of site-specific immunosuppression for reducing systemic exposure while increasing intra-graft concentrations of the drug. Therefore, in this study, we tested whether a single intra-graft injection tacrolimus could promote VCA survival. METHODS: Brown Norway-to-Lewis hind limb transplantations were performed, and animals were left untreated (group I), treated with a daily injection of 1-mg/kg tacrolimus for 21 days (group 2) or injected with 7-mg tacrolimus directly into the transplanted limb on day 1 (group III). Graft rejection was monitored, and animals were sacrificed at grade 3 rejection or 200 days after transplantation. RESULTS: Intra-graft injection of tacrolimus significantly prolonged allograft survival as compared to untreated animals or animals treated with systemic tacrolimus. Half of the intra-graft-treated rats rejected their graft on average at day 70.5. Interestingly, the other half remained rejection-free for more than 200 days without signs of kidney or liver toxicity. In these animals, tacrolimus was detected in the VCA skin but not in the blood until day 200. Long-term survival was not linked to induction of donor-specific tolerance but to a higher level of lymphocyte chimerism. CONCLUSIONS: Intra-graft delivery of tacrolimus may promote VCA survival by increasing tissue drug availability and promoting the establishment of transient chimerism and thus long-term graft acceptance.

Abdominal wall reconstruction with Two-step Technique (TST): a prospective study in 20 patients.

Abdominal wall defects continue to be a challenging problem for reconstructive surgeons. The aim of our study was to report a 3-year experience using a simple Two-step Technique (TST) to treat abdominal wall defects. Between January 2008 and December 2010, 20 patients with abdominal wall defects were treated by TST. Patients had a mean age of 37·5 ± 14·9 years (range: 22-85 years); 5 were women and 15 were men. The size of the defects was prospectively analysed. Early and late complications were recorded. Hospital stay, post-procedure downtime and patient overall satisfaction were systematically assessed. A secondary defect resulting from self-manipulation and an infection were responsible for a complication rate of 10%. Both underwent successful surgical revision which led to full resolution. The average hospital stay was 11·2 ± 4·9 weeks for the series. Long-term complications were scar hyperpigmentation in 11 cases, scar hypertrophy in 5 cases and scar widening in 3 cases. Mean patient satisfaction was 8·3 ± 0·5 [visual analogue scale (VAS) 0-10]. Average downtime post surgery was 4·1 ± 1·2 weeks. The mean follow-up was 24·6 ± 6·7 months. Reconstruction of abdominal wall defect with the TST is a reliable and reproducible technique. This technique provides excellent outcomes, and we anticipate that it will become widespread in the near future.

A single localized dose of enzyme-responsive hydrogel improves long-term survival of a vascularized composite allograft.

Currently, systemic immunosuppression is used in vascularized composite allotransplantation (VCA). This treatment has considerable side effects and reduces the quality of life of VCA recipients. We loaded the immunosuppressive drug tacrolimus into a self-assembled hydrogel, which releases the drug in response to proteolytic enzymes that are overexpressed during inflammation. A one-time local injection of the tacrolimus-laden hydrogel significantly prolonged graft survival in a Brown Norway-to-Lewis rat hindlimb transplantation model, leading to a median graft survival of >100 days compared to 33.5 days in tacrolimus only-treated recipients. Control groups with no treatment or hydrogel only showed a graft survival of 11 days. Histopathological evaluation, including anti-graft antibodies and complement C3, revealed significantly reduced immune responses in the tacrolimus-hydrogel group compared with tacrolimus only. In conclusion, a single-dose local injection of an enzyme-responsive tacrolimus-hydrogel is capable of preventing VCA rejection for >100 days in a rat model and may offer a new approach for immunosuppression in VCA.

Reconstruction of large mandibulofacial defects with the composed double skin paddle fibula free flap: a review of 32 procedures.

OBJECTIVES/HYPOTHESIS: The purpose of this study was to analyze our experience with the composed double skin paddle fibula free flap to reconstruct large mandibulofacial defects. STUDY DESIGN: Between 2006 and 2011, a total of 32 composed double skin paddle fibula free flap procedures were performed on 32 patients (mean age 54.4 ± 9.7 years, mean follow-up period of 3.4 ± 1.7 years). METHODS: A chart review was drawn up to determine the type of defects covered by each skin paddle, the vascular anatomy, the origin of the perforators, and any associated complications. RESULTS: The distal septocutaneous skin paddle (Nakajima type B) was used for the reconstruction of the floor of the mouth in most cases. The proximal paddle (Nakajima type D) was used for base of the tongue, mobile tongue, soft palate, internal cheek, inferior lip, and the skin of the chin and neck. The lateral soleus pedicle arose from the fibular pedicle in 28 cases and directly from the tibial-fibular trunk in four cases. There were two partial soleus skin paddle losses. Seven complications required revision surgery: due to a cervical abscess in two cases, due to a hematoma in two cases, due to a disunion of the second skin paddle leading to an orostoma in two cases, and due to an exposition of the osteosynthesis material in one case. CONCLUSION: In large mandibulofacial defects, a second skin paddle raised on the soleus perforators may be of benefit when reconstructing the soft palate, neck, cheek, or tongue as the length of its pedicle renders a second free flap unnecessary. LEVEL OF EVIDENCE: IV.

Functional-conservative treatment of extra-articular physeal fractures of the proximal phalanges in children and adolescents.

BACKGROUND: Fractures of the proximal phalanges of the fingers are common injuries in children and adolescents. The majority can be treated by closed reduction and splinting, and complications are rare. The purpose of the prospective study was to document the results of functional-conservative treatment of extra-articular physeal fractures using either a functional forearm cast or the Lucerne Cast (LuCa). METHODS: Clinical and radiographic results of 13 pediatric patients having 13 extra-articular physeal fractures (e.g., juxta-epiphyseal fractures, Salter-Harris type I or II physeal fractures) of the proximal phalanges were recorded through a minimum follow-up of 6 months. Intra-articular physeal fractures (Salter-Harris type III or IV), fractures involving the proximal interphalangeal joint (PIPJ), pathological fractures, open fractures, and concomitant injuries of the tendons were excluded. RESULTS: Fracture consolidation was achieved in all cases within 4 weeks. No palmar apex angulations, no rotational deformities, and no PIPJ extension lags could be observed. All patients achieved full total active range of motion within 3 months. CONCLUSIONS: Well-reduced extra-articular physeal fractures of the proximal phalanges can be effectively treated using functional-conservative casts. Although children may need a functional forearm cast, a LuCa is adequate in compliant adolescents.Level of Evidence The level of evidence for the study is Level II (therapeutic studies).

Predicting grip strength and key pinch using anthropometric data, DASH questionnaire and wrist range of motion.

PURPOSE: The objective of this study was to examine the influence of anthropometric data, occupational manual strain, DASH (disability of arm, shoulder and hand) score and range of motion (ROM) on grip strength and key pinch. An additional goal was to develop models that enable the prediction of hand strength using the aforementioned parameters. METHODS: Normative data generated from a healthy working population (n = 750) served as basis for the statistical analysis. Prediction models for hand strength were developed using multivariate regression analysis. RESULTS: Gender, body weight and height, BMI and extension ROM correlate positively, age and DASH score, however, correlate negatively with grip strength and key pinch. Occupational manual strain has no influence on hand strength. The predictive power of the developed models was 68.4 % for grip strength and 57.1 % for key pinch. CONCLUSIONS: The developed models enable the prediction of hand strength using easily obtainable data points. The models will have application in clinical practice, physiological studies, medical evidence and rehab decisions.

Normative data on wrist function.

PURPOSE: In clinical day-to-day life, grip strength, key pinch, and range of motion (ROM) serve to objectively evaluate treatment outcomes on wrist interventions. The goals of this study were to generate normative values of wrist function including the parameters of grip strength, key pinch, wrist ROM, and Disabilities of the Arm, Shoulder, and Hand (DASH) scores in a healthy, working population, and to investigate the influence of age, sex, body weight and height, handedness, and work strain. METHODS: We clinically examined 750 volunteer working subjects (363 women and 387 men, all white). We divided subjects into 2 groups depending on whether their labor involved high or low manual strain. We recorded participants' height, weight, grip strength, pinch strength, and wrist ROM. Each participant filled out a DASH questionnaire. RESULTS: Grip strength and pinch strength showed a maximum at between 30 and 49 years of age. In men, body mass index, body height, and weight all correlated with grip strength and pinch grip. Whereas women exhibited greater grip strength on the right side, men showed nonsignificant greater grip strength on the left side. Wrist ROM was greatest for ages ranging between 18 and 29 years. The average DASH value for all male subjects was significantly less than that of female subjects. In a healthy working population, the DASH score increased yearly by an average of 0.2 points in men and 0.3 points in women. CONCLUSIONS: This study showed that in a healthy working population, people 30 to 49 years of age had the highest grip strength and pinch strength. Age positively correlated with the DASH score and inversely related to wrist ROM. Persons employed in jobs with high manual strain presented with lower wrist ROM and higher DASH scores. CLINICAL RELEVANCE: These data help to objectively evaluate wrist function and the effectiveness of therapeutic interventions.

[Blood flow assessment with magnetic resonance imaging after 1.9 µm diode laser assisted arterial micronastomoses]. / Évaluation du flux sanguin par imagerie en résonance magnétique fonctionnelle après anastomoses artérielles assistées par laser diode 1,9µm.

INTRODUCTION: The most important factor for successful free-flap transfer and replantations is a well-executed anastomosis. The aim of this study is to assess blood flow after laser assisted arterial microanastomosis (LAMA) using a 1.9 µm diode laser. MATERIALS AND METHODS: LAMA was performed on a series of 10 carotidis on Wistar rats. Two 10/0 stay sutures and a standard laser tissue welding technique (λ: 1.9 µm; power: 120mW) were used. Similarly, a series of 10 conventional arterial anastomosis were performed (CSMA). For the two groups, contralateral non-operated carotidis were used as control. A positioning sequence, an anatomical sequence, an angiographic sequence and a flow sequence were performed 1 day after operation and then after 1, 4 and 8 weeks. RESULTS: The arterial patency rate was 100% at the time of surgery. The mean clamping time was 7.2 min in the LAMA group compared to 10.7 min in the CSMA group. In the angiographic sequence, there were no aneurysms in both groups for all observation periods. At postoperative day 1, the mean loss of blood flow at the level of anastomosis in the LAMA group was 6% compared with 14% in the CSMA group. After 1, 4 and 8 weeks, there was an unhooking of the blood flow in the CSMA group: the loss of blood flow was 23%, 27% and 31% respectively, compared with 10%, 12% and 13% in the LAMA group. Moreover, one case of thrombosis was observed in the CSMA group after 1 week. CONCLUSION: The flow-MRI emphasizes that 1.9 µm diode laser assisted microvascular anastomosis appears to be a consistent and reliable technique. These results show that 1.9 µm diode laser assisted microvascular anastomosis has potential for further development in the near future.

Laser assisted septal cartilage reshaping (LASCR): A prospective study in 12 patients.

BACKGROUND AND OBJECTIVES: Occurring in one-third of the population, nasal obstruction is the most common complaint in an average rhinologic practice. The etiology is usually a deviation of the nasal septum, although other conditions, such as turbinate hypertrophy, can also cause nasal obstruction. Our team has already demonstrated that laser assisted cartilage reshaping can be used effectively for the correction of ear protrusion. This study aims to evaluate laser assisted septal cartilage reshaping (LASCR) to treat septal deviation. STUDY DESIGN: Between March 2009 and September 2009, 12 patients (8 males, 4 females-mean age: 23 years) underwent LASCR for treatment of septal deviation. The mean NOSE score was 11.6. Preoperative examination included rhinomanometry and nasal endoscopy to exclude inferior turbinate or adenoid hypertrophy. Both sides of the septum were irradiated using a 1,540 nm laser connected to a 4 mm spot handpiece with integrated cooling (fluence: 50 J/cm(2)). Contact cooling made the treatment tolerable, but topical anesthesia was still required. Immediately after the procedure, an internal splint was inserted into the nostril and kept for 7 days. The NOSE score was calculated at 1 week, 1 month, and 3 months post-procedure and a rhinomanometry was carried out at 3 months. RESULTS: The entire procedure took an average of 20 minutes. For all procedures, there were no lesions of the septal mucosa. Three months post-op, mean NOSE score improved from 11.6 to 5.3. Rhinomanometry assesses an increase in airflow (+19%) and improvement to air inflow resistance (-16%), confirming a subjective improvement. In seven adults, the expected septal reshaping was achieved. In five adults, incomplete septum reshaping was observed. In three patients it was correlated to anatomical variations: a thick septum in two cases and a long septum in one case. In the remaining two patients, it was due to insufficient fluence. In these cases, insufficient local anesthesia did not allow us to finish the procedure and the patients received a fluence of 30 J/cm(2) only. Those patients were re-treated at 3 months at 50 J/cm(2) fluence and all achieved suitable reshaping. CONCLUSION: LASCR is a safe and less morbid approach to surgical septoplasty. Since significant variability in the cartilaginous elements of the nose is the rule rather than the exception, some improvements in the technique are still required.

Outcomes after 1.9-microm diode laser-assisted anastomosis in reconstructive microsurgery: results in 27 patients.

BACKGROUND: Microvascular surgery has become an important method for reconstructing surgical defects resulting from trauma, tumors, or burns. The most important factor for successful free flap transfer is a well-executed anastomosis. This study was performed to review the authors' experience with a 1.9-microm diode laser in microsurgery, with special attention to outcomes and performance of the technique. METHODS: Between January of 2005 and December of 2007, 27 patients underwent microsurgery with a 1.9-microm diode laser at the authors' institute. The patients had a mean age of 31 years (range, 2 to 59 years); 14 patients were women and 13 patients were men. This technique was used for digital replantations (n = 2) and for free flap transfer (n = 27). Causes of the defects were trauma (n = 14), tumor (n = 9), congenital (n = 2), burn (n = 1), infection (n = 1), arthritis (n = 1), and dog bite (n = 1). Laser-assisted microvascular anastomosis was performed with a 1.9-microm diode laser after placement of equidistant stitches. The following parameters were used: spot size, 400 microm; power, 125 mW; time depending on vessel size (0.8 to 1.8 mm); and fluence varying from 70 to 200 J/cm. RESULTS: Three surgical revisions following hematoma and one rupture of the arterial anastomosis leading to a free deep inferior epigastric perforator flap necrosis resulting from high-dose radiotherapy before surgery occurred after laser-assisted microvascular anastomosis, accounting for an overall success rate of 96.6 percent. CONCLUSION: This study reports the numerous benefits of the technique: easier performance of vascular anastomosis with difficult access, decrease of reperfusion bleeding and complications, and a short learning curve.

Laser-assisted cartilage reshaping (LACR) for treating ear protrusions: a clinical study in 24 patients.

BACKGROUND: Protruding ears are the most common congenital ear deformity, with a frequency of 13.5%. Since 1845 and the first works of Dieffenbach, over 170 classical surgical methods have been proposed to correct it. We introduced laser-assisted cartilage reshaping (LACR) in 2004 as an alternative to invasive surgical otoplasty. METHODS: Between January 2008 and June 2008, 24 patients underwent LACR for treatment of bilateral ear protrusion. Fourteen adults and ten children were treated (mean age = 16.0 years, range = 6-45 years). No anesthesia was used. Both sides of the entire helix and the concha were irradiated using a 1540-nm laser connected to a 4-mm spot handpiece with integrated cooling. Fluences varying from 70 up to 84 J/cm(2) were applied. Immediately after the irradiation, silicone elastomer was inserted inside the helix to give it the desired shape. After 3 minutes a solid mold was obtained. Patients were asked to keep this mold in place at all times with a bandage wrapped around the head for the first 3 weeks and then for an additional 3 weeks only during the night. A non-steroidal anti-inflammatory drug (NSAID) was prescribed to the patients for 3 days. At 1, 30, 60, and 90 days after the procedure, ears were checked and photographs were taken. Clinical follow-up at 1 year was obtained via direct patient contact or over the telephone. RESULTS: The treatment was well tolerated. No hematomas or skin necrosis occurred. Contact dermatitis was observed in four children and two adults as a result of inappropriate mold design. These patients stopped wearing the mold and the shape of their ear did not improve. For the remaining 18 patients (6 children and 9 adults), the expected ear reshaping was obtained (fluence was 84 J/cm(2)). For three other adults, incomplete reshaping of the ears was observed and can be correlated to a lower fluence (70 J/cm(2)). CONCLUSION: LACR, performed without any anesthesia, is a safe and less morbid approach to surgical otoplasty.

Acute digital ischemia: a neglected microsurgical emergency. Report of 17 patients and literature review.

This study was performed to review our 16-year experience in acute finger ischemia. A review of the literature was also performed. A retrospective chart review of 17 patients, 14 men and 3 women, was conducted. Etiologies were ulnar aneurysm in 11 cases, atrial fibrillation in five cases and thoracic outlet syndrome in one case. Upto the palmar superficial arch, embolus due to atrial fibrillation or thoracic outlet syndrome could be loosened by a Fogarty catheter. In cases of aneurysm of the ulnar artery, we performed each time an aneurysm resection followed by direct anastomose alone, while three patients had additional grafts: artery graft (epigastric artery) or reversed vein grafts (superficial forearm vein). Microsurgical dissection of the digital collateral arteries enabled us to perform a thrombectomy. The transversal arteriotomies were closed after the collateral arteries were washed. The immediate perfusion of digit after the reconstruction of the aneurysm was each time excellent. The disoccluded vessels, investigated by Allen testing and Doppler ultrasound, were all patents. Two patients suffered from a small ulcer of the small fingertip that disappeared after 2 weeks. One patient had a 30 degrees ischemic flexion contracture in the metacarpophalangeal joint and 25 degrees flexion contracture in the proximal interphalangeal joint of the third digit. With regards to long-term outcomes, no secondary amputations were necessary and there was no recurrence after a mean follow-up of 10.7 years. Diagnostic of acute digital ischemia is often neglected. An early recognition and an aggressive microsurgical treatment are necessary to ensure low morbidity.